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Fostering Multidisciplinary Cancer Care in a Community Setting

Authors: Ralph V. Boccia, MD; Michael Choti, MD, MBAFaculty and Disclosures


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NARRATOR: Modern cancer therapy often involves a variety of treatments, ranging from surgery and radiation to intravenous chemotherapy, injectable antibodies, and oral drugs. The cancer care team may include not only the surgeon, radiation oncologists, and medical oncologists but also the expert in diagnostic imaging, the pathologist, the genetic counselor, the oncology nurse, the physical therapist, the hospital pharmacist, and others. Well-coordinated multi- and interdisciplinary care is the current standard in large tertiary medical centers and academic medical institutions, where patients can obtain consults and see specialists who all practice in one central location. But what about cancer care in the community? Most patients with cancer are treated by community oncologists. How can community practitioners work with colleagues to render truly multidisciplinary treatments despite significant challenges?

In this expert interview, Drs. Ralph Boccia and Michael Choti discuss typical treatment patterns and some of the ways in which practitioners can improve professional communication.

Ralph Boccia, MD: Hello, I'm Dr. Ralph Boccia, a community oncologist from the Center for Cancer and Blood Disorders in Bethesda, Maryland. I recently had an opportunity to speak with Dr. Michael Choti, Professor of Surgical Oncology at Johns Hopkins Hospital in nearby Baltimore, Maryland, about the delivery of cancer care in the community and the value of team approaches. Multidisciplinary conferences seem to be developing more commonly at many institutions. What I'd like to do is ask you, Michael, how do you feel about the delivery of cancer care in multidisciplinary teams, and that particular approach to managing patients with cancer?

Michael Choti, MD: Well, Ralph, as you know, we've managed a lot of patients together, [and] this is an important area to discuss today. Because really, multidisciplinary care, the team approach for managing cancer patients, more and more I think is becoming important. I think there's evidence to suggest that this kind of integrated approach -- with imaging, medical oncology, surgical oncology, radiation oncology, genetic counselors, the whole team approach -- is really the optimal way to manage, rather than the vertical approach. And I think there are data to support [the idea that] those patients get better care in that setting.

Dr. Boccia: How can multidisciplinary care be delivered in the community? What would you feel would be a best approach to that type of delivery, given the constraints of geography and the business of practitioners? We know, for instance, that somewhere between 80% and 90% of cancer care is delivered in the community. It's a bit different from the academic setting, where perhaps there might be more research that goes [on] than in the typical community practice.

Dr. Choti: Well, you're right. In our academic center, it is very different. How we deliver multidisciplinary team approach care in the academic center is different. Patients are seen in multidisciplinary clinics, for example -- something not easily accomplished, I think, in the community -- where new patients are seen by multiple team members that same day, often. They can be seen by multiple providers, sometimes together. And multidisciplinary conferences with all the providers, including radiologists and so forth, are present there at a multidisciplinary conference at the same time. How that can be delivered in the community setting, I think one needs to perhaps be creative. How is it done in your environment? How do you care for patients, for example, when you really feel that a certain cancer patient may be benefited by a team approach?

Dr. Boccia: Well, we perhaps have a little bit of a selective type of setting. We know, for instance, throughout the country, there are many different settings where community physicians may practice in cities where they have access to tumor boards on a regular basis. And compare that, for instance, and contrast, to physicians out in rural areas, where perhaps it's 50 miles to a hospital, and they really are on the proverbial front-lines taking care of patients, literally, on their own.

In our center we have several multidisciplinary conferences that occur on a rotating basis each month. It's probably not as intense as it might be in an academic setting, where perhaps these same conferences could take place on a weekly basis, but we have multiple tumor type conferences that go on each month. And so on that basis we have the opportunity, at least, to present cases in front of the multidisciplinary teams, a multidisciplinary tumor board, if you'll have it described as such. And even in our breast cancer conference, we have an intake conference that discusses virtually every case that comes through the hospital in a bullet format, where the multidisciplinary members of the teams can discuss whether it's most appropriate for chemotherapy, radiation, or hormonal therapy, etc.

I suspect, in fact, I know, that that's very different from what occurs in many other settings. We understand that taking care of 80% to 90% of the patients in the country puts a bit of a burden on us, with regard to the volume of patients that must be managed on a regular basis, since there's a limited number of oncologists in the country and, sadly, an ever-increasing number of cancer patients in the country. The timing, as well as the geography, is obviously important.

Dr. Choti: Also the volume of a specific disease. Often the community oncologist takes care of multiple different [tumors]. We have the advantage when we're specific GI or breast or GYN, for example, where it's easier to develop a team that all takes care of the same type of patients; it's a little bit harder when you're dealing with multiple disease types. What are some of the other barriers? It's sometimes harder to get surgeons, for example, to [come to] multidisciplinary conferences. Often in the community, there are differences, geographically, as you mentioned -- providers are working in different centers. What are some of the other barriers to really, as you mentioned, trying to develop these integrated teams in the community?

Dr. Boccia: I think perhaps the biggest barrier is the lack of the ability to organize, as you put it, a large group of practitioners who will have the ability to come together in a scheduled fashion all at the same time to deliver this sort of care. If you practice in a community cancer center, you obviously have people that are designated to managing those sorts of issues. But if you're not a member of a community cancer center, and the vast majority of community oncologists in this country are not, then there's no one place where you can go and have all of that efficiently organized. I think probably the biggest barrier is just that it is the scheduling of time, and some are governed by the geography of the different practitioners.

Dr. Choti: That's interesting. That's an interesting problem. Another thing we deal with is this idea of integrating multidisciplinary care across centers. I know you and I have a lot of mutual patients, and it's not as though we can attend a conference together. I'm at an academic institution in Baltimore, you're practicing in a large community practice in Bethesda, so we're geographically apart, and often there may be patients that we want to manage together. Tell me how we do that on occasion. I guess it's developing the communication skills to integrate a multidisciplinary team across both community and academic centers.

Dr. Boccia: Communication is clearly the key to this, and it is developing a rapport that will accentuate and facilitate, I think, those communications. We live in an era, the electronic age, where we don't travel nearly as much as we used to. Companies now are beginning to utilize different formats for bringing their members together and discussing issues that need to be discussed: virtual meetings, I think, with Webcasts and all the opportunities that computers present to us.

It seems to me that communication is in evolution right now. Instead of picking up a phone and calling someone, hopefully we'll be at a point where [we'll realize], as we've discussed in the past, the potential use of oncology chat rooms. Perhaps that will be a way to organize different multispecialty practitioners together in a way that we can, in fact, emulate a multidisciplinary tumor conference electronically.

Dr. Choti: Exactly. But it's complicated. I know my area of interest is management of metastatic colorectal cancer, an area where we often integrate therapy, particularly in patients who may be candidates for surgical therapy, resection of liver metastases, for example. It's not always that easy; we can't send every patient with metastatic colorectal cancer, for example, to academic centers. It's a problem, and it's not always an easy strategy to know when it's appropriate to triage or to refer a patient. It's not a matter of having strict criteria. Sometimes there may be clear cases in which it's more appropriate to manage that patient more vertically, if you will. Primarily, let's say, with chemotherapy in a patient with advanced colorectal cancer, there may be a patient that's relatively easily defined as let's say resectable metastases, but sometimes there's a gray zone. Here we are in a situation [with] a patient [where] we may want to integrate chemotherapy prior to liver resection in a resectable situation. We may want to manage chemotherapy for a prolonged duration until a patient becomes, for example, resectable and then move in.

I know one example. You may have a patient where they may be a candidate for curative intent therapy where you may communicate with me, send me the scans, for example. We may communicate by e-mail, or by faxes, or mailing a scan or e-mailing scan results, for example. I may tell you, "Well, let's go with several cycles of chemotherapy," before I even see the patient. I think that it is a strategy, as well, in a situation like that. Sometimes in breast cancer, in rectal cancer, we may integrate care in such a way.

Dr. Boccia: It seems to me that it's incumbent upon both of us, both the academic centers as well as the community centers, to begin to develop ways to communicate better and to interact together. And with this new electronic age, it seems to me that since picking up a telephone or faxing, sending a patient up for a consult -- especially when many times you would like to review the case actually before seeing the patient -- that the electronic transmission of that data would seem not only appropriate, but it could facilitate a lot of that. And if in fact there were some way to have a virtual tumor board, where perhaps the local academic center could interact with the local community center in an electronic format periodically, perhaps once a week, have an open session that could be Web-based or chat room-based, then a lot of that data could in fact be transmitted electronically to all of the members of the tumor board, being either on the community side or the academic side.

Obviously, the academic institutions have an interest in further developing these more complicated procedures and therapies. In research, the use of clinical trials, especially for earlier drug development [is vital], and the community, in fact, [may] be able to provide the patients at the appropriate time. And so the communication across these lines might actually facilitate that: Give the community access to academics and give academics access to the community.

Dr. Choti: I agree. And there could be other strategies. There could be more formal relationships, in fact. There could be kind of a hub-and-spoke relationship, where there could be more formal affiliations between the community and academic centers in specific situations. And I know in certain centers we're developing some of those relationships as well, both for patient care but also for enhancing clinical trials and clinical research. I think it's useful. Yes, those electronic systems are useful, but there's nothing like getting to know somebody. There's nothing wrong, also, with still picking up the phone. Because I know that as we develop relationships like that, then I think patient care management is certainly improved. I think this is really a very important topic to discuss today.

This activity is supported by an educational grant from Amgen, Genentech, AstraZeneca and sanofi-aventis.

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